www.ccsa.ca • www.cclt.ca Rapid Review Canadian Centre on Substance Abuse • Centre canadien de lutte contre les toxicomanies Page 1 May 2016 Effectiveness of Multidimensional Family Therapy for Reducing Substance Use among Youth Key Messages Multidimensional family therapy (MDFT) is a promising family-based intervention for reducing substance use among youth. Compared to those involved in group and cognitive behavioural therapies, those who participated in MDFT: o Were less likely to be dependent and used substances less frequently at a 12-month follow-up period; and o Experienced better outcomes related to substance use severity, particularly among high-risk youth. MDFT resulted in significantly greater reductions in both alcohol and cannabis use compared to group therapy. Research specific to Canada is needed to substantiate this evidence and fill knowledge gaps related to the application of MDFT for reducing substance use for different age, gender and ethnic groups, and for those with concurrent disorders. Strengthening Our Skills: Canadian Guidelines for Youth Substance Abuse Prevention Family Skills Programs is an evidence-based resource available to help guide the adaptation of family-based programs to a local context. The findings in this rapid review are limited by the restrictive parameters of the methodology used to perform the review. As a result, the findings might not represent a comprehensive assessment of the state of knowledge about this topic and should be considered in light of their limitations. Further, the diversity of language used in the field of addiction is such that different sources often use different terms. This rapid review attempts to maintain consistency and accuracy with the source reporting the evidence by using the terms presented in the original publication. The audience for this document includes addiction treatment providers and specialists, policy makers, healthcare practitioners, the research community and youth support workers. Context Youth is a time of significant growth and change, including significant brain development. It is also the period when risk-taking and substance use most commonly begins. Parts of the brain associated with reward, motivation and impulsivity typically mature early, while areas of the brain that moderate risk mature later (Spear, 2013). This lag means that young people can be more prone to risk-taking behaviour than the general population. Youths’ smaller body size and higher sensitivity to the effects
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www.ccsa.ca • www.cclt.ca Rapid Review
Canadian Centre on Substance Abuse • Centre canadien de lutte contre les toxicomanies Page 1
May 2016
Effectiveness of Multidimensional Family Therapy
for Reducing Substance Use among Youth
Key Messages
Multidimensional family therapy (MDFT) is a promising family-based intervention for reducing
substance use among youth.
Compared to those involved in group and cognitive behavioural therapies, those who
participated in MDFT:
o Were less likely to be dependent and used substances less frequently at a 12-month
follow-up period; and
o Experienced better outcomes related to substance use severity, particularly among
high-risk youth.
MDFT resulted in significantly greater reductions in both alcohol and cannabis use compared
to group therapy.
Research specific to Canada is needed to substantiate this evidence and fill knowledge gaps
related to the application of MDFT for reducing substance use for different age, gender and
ethnic groups, and for those with concurrent disorders.
Strengthening Our Skills: Canadian Guidelines for Youth Substance Abuse Prevention Family
Skills Programs is an evidence-based resource available to help guide the adaptation of
family-based programs to a local context.
The findings in this rapid review are limited by the restrictive parameters of the methodology used to
perform the review. As a result, the findings might not represent a comprehensive assessment of the
state of knowledge about this topic and should be considered in light of their limitations. Further, the
diversity of language used in the field of addiction is such that different sources often use different
terms. This rapid review attempts to maintain consistency and accuracy with the source reporting the
evidence by using the terms presented in the original publication. The audience for this document
includes addiction treatment providers and specialists, policy makers, healthcare practitioners, the
research community and youth support workers.
Context
Youth is a time of significant growth and change, including significant brain development. It is also
the period when risk-taking and substance use most commonly begins. Parts of the brain associated
with reward, motivation and impulsivity typically mature early, while areas of the brain that moderate
risk mature later (Spear, 2013). This lag means that young people can be more prone to risk-taking
behaviour than the general population. Youths’ smaller body size and higher sensitivity to the effects
Multifamily education intervention (MEI): consists of interventions used in mental health to inform
and support extended family of the substance-involved youth (i.e., parents, relatives, etc.).
Personal Experience Inventory (PEI): multiscale self-report measure assessing substance use
problem severity and psychosocial risk.
Personal Involvement with Chemicals (PIC): a 29-item subscale of the PEI focusing on the
psychological and behavioural depth of substance use involvement and related consequences in the
past 30 days.
Effectiveness of Multidimensional Family Therapy for Reducing Substance Use among Youth
Canadian Centre on Substance Abuse • Centre canadien de lutte contre les toxicomanies Page 10 Page 10
Appendix B: Search Strategy
The search strategy was developed and tested through an iterative process by an experienced
medical information specialist in consultation with the review team. MEDLINE and the Psychology
and Behavioral Sciences Collection on Ebsco, PsycINFO on APA PsycNET, and the Cochrane Library
on Wiley were all search. A grey literature search of relevant organizational sites (e.g., Centre on
Addiction and Mental Health [CAMH], National Institute of Mental Health, Substance Abuse and
Mental Health Services Administration [SAMHSA]) and databases (e.g., Project Cork, HSRProj, TRIP)
was also undertaken. All database and grey literature searches were performed between the dates
and October 30 and November 2, 2015.
Strategies used a combination of controlled vocabulary (e.g., “Substance-Related Disorders,” “Family
Therapy,” “Adolescent Behavior”) and keywords (e.g., drug abuse, MDFT, adolescent). Vocabulary
and syntax were adjusted across databases. Results were limited to the publication years 2010 to
the present. When possible, animal-only and opinion pieces were removed from the results.
Additional references were also sought through hand-searching the bibliographies of relevant items.
Specific details regarding the database search strategies are available upon request.
Effectiveness of Multidimensional Family Therapy for Reducing Substance Use among Youth
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Appendix C: Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA)
Statement
Effectiveness of Multidimensional Family Therapy for Reducing Substance Use among Youth
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Appendix D: Characteristics of Included Systematic
Reviews
Citation Relevant Studies Included
Study Design & Objectives
Participant Characteristics
Intervention & Comparator(s)
Relevant Reported Outcomes
Filges et al. (2015)
Dennis et al. (2004), Liddle et al. (2001), Liddle et al. (2008a), Liddle et al. (2009), Rigter et al. (2011)
Objectives: to evaluate the current evidence on the effects of MDFT on drug abuse reduction for young people in treatment for non-opioid drug abuse, as well as moderators of reduction effects.
Design: Systematic review and meta-analysis of experimental, quasi-experimental or non-RCTs published to October 2008.
N=5 unique RCTs reported in 16 papers
Setting: 3 single site studies (US), 2 multisite studies (US – Miami; Europe – Belgium, France, Germany, The Netherlands, Switzerland)
Study duration: up to 12-mo follow-up
Total participant population: n=1,239; range between studies n=83-450;
Youth aged 11-18 years
Mean age: 13.7-16.3 years
Gender: 73-86% male
Ethnicity: 18-72% Black, 3-51% White, 2-42% Hispanic; 1 study reported 40% first or second generation foreign descent
DOC: Cannabis in 4 studies, the other did not report DOC. One reported 49% cannabis and 51% poly-drug as DOC.
MDFT: mean of 12-48 sessions (2/wk) lasting 3-6 months (n=373-408)
&
Individual- or group-based approaches (n=390-431):
CBT: n=53-59
IP (TAU): n=195
AGT or MEI: n=28 or 34
MET/CBT5 or ACRA: n=99 or 100
Drug abuse problem severity at 6-mo follow-up
MDFT vs. MET/CBT5 + AGT + CBT + IP + PGT: SMD, -0.35; 95% CI, -0.59 to -0.11; p=0.004
MDFT vs. MET/CBT5 + MEI + CBT + IP + PGT: SMD, -0.31; 95% CI, -0.53 to -0.10; p=0.004
MDFT vs. ACRA + AGT + CBT + IP + PGT: SMD, -0.33; 95% CI, -0.59 to -0.08; p=0.01
MDFT vs. ACRA + MEI + CBT + IP + PGT: SMD, -0.30; 95% CI, -0.53 to -0.07; p=0.01
Drug abuse frequency reduction at 6-mo follow-up
MDFT vs. MET/CBT5 + CBT + IP + PGT: SMD, -0.24; 95% CI, -0.43 to -0.06; p=0.01
MDFT vs. ACRA + CBT + IP + PGT: SMD, -0.25; 95% CI, -0.40, -0.11; p=0.0007
Drug abuse problem severity at 12-mo follow-up
MDFT vs. MET/CBT5 + AGT + CBT + IP + PGT: SMD, -0.25; 95% CI, -0.39 to -0.10; p=0.0007
MDFT vs. MET/CBT5 + MEI + CBT + IP + PGT: SMD, -0.27; 95% CI, -0.04 to -0.11; p=0.001
MDFT vs. ACRA + AGT + CBT + IP + PGT: SMD, -0.23; 95% CI, -0.39 to -0.06; p=0.007
MDFT vs. ACRA + MEI + CBT + IP + PGT: SMD, 0.25; 95% CI, -0.42, -0.07; p=0.007
Drug abuse frequency reduction at 12-mo follow-up
MDFT vs. MET/CBT5 + CBT + IP + PGT: SMD, -0.28; 95% CI, -0.63 to 0.07; p=0.11
MDFT vs. ACRA + CBT + IP + PGT: SMD, -0.28; 95% CI, -0.63 to 0.07; p=0.11
EMCDDA (2014)
Dennis et al. (2004), Liddle et al. (2001), Liddle et al. (2004), Liddle et al. (2008a), Rigter et al. (2013)
Objective: to assess the evidence on the effectiveness of MDFT, compared to other therapies or a placebo, in treating illicit drug misuse in youth.
Design: Systematic review of studies with an experimental design (e.g., RCTs, cluster RCTs)
N=5 unique RCTs reported in 22 papers
1,539 participants total (range: 83-450)
Youth aged 11-18 years
Non-opioid drug abuse
Mean age: 13.7-16.3 years
Gender: 74-85% male
Ethnicity: 18-72% Black, 3-61% White, 4-42% Hispanic, 0-40% other
DOC: Varied between studies though cannabis dependence or abuse was
MDFT: 12-15 sessions delivered over 12-14wks; majority conducted at home.
&
IP: including MI and CBT in addition to individual substance misuse counselling.
AGT or MEI: adolescent or family group
MDFT vs. AGT:
Reduction in drug use (alcohol, cannabis and other drugs) (NS)
MDFT vs. CBT:
Reduction in cannabis use in the last 30 days at 12-mo follow-up (NS)
Reduction in use of drugs (other than cannabis and alcohol) at 12-mo follow-up (-91% vs. 92%) (SS)
Higher proportion reporting minimal substance use (no use/use on only 1 occasion of alcohol or drugs) at 12-mo follow-up (64% vs. 44%) (SS)
Reduction in substance use frequency in HS and LS groups at 12-mo follow-up (NS for either group)
Frequency of alcohol use at 12-mo follow-up (15% vs. -18%) (NS)
Reduction in severity of drug use problems at 6-mo (not reported) and 12-mo follow-up (-59% vs. -29%) (SS) but not at intake or treatment completion (SNR)
Effectiveness of Multidimensional Family Therapy for Reducing Substance Use among Youth
Canadian Centre on Substance Abuse • Centre canadien de lutte contre les toxicomanies Page 13 Page 13
Setting: 3 single site studies (US), 2 multisite studies (US – Miami; Europe – Belgium, France, Germany, The Netherlands, Switzerland)
Study duration: 12-mo follow-up for all RCTs
predominant in all; one reported 49% cannabis and alcohol vs. 51% polydrug.
therapies delivered in community clinical setting.
CBT: individual, office-based outpatient.
PGT: skills and support training delivered in clinic office.
MET/CBT5: 2 sessions of MET + 3 sessions CBT; duration of 6-7wks.
ACRA: 10 individual sessions with adolescent, 4 sessions with caregiver, 2 with whole family; duration 12-14wks.
Reduction in severity of drug use problems for HS subgroup (SS) but not LS group (NS)
MDFT vs. PGT:
Reduction in 30-day frequency of substance use (alcohol and drugs) at 12-mo follow-up (-85% vs. -28%) (SS)
Reduction in frequency of any drug use days at 12-mo follow-up (-72% vs. -26%) (SNR)
Increased probability of abstinence at 12-mo follow-up (2.20; 95% CI, 0.77 to 6.33) (SS)
Reduction in number of substance-related problems at 12-mo follow-up (-79% vs. -27%) (SS)
Reduction in number of participants reporting any substance use problems (-65% vs. -32%) (NS)
MDFT MET/CBT5:
Increase in number of days abstinent from cannabis use at 12-mo follow-up (257 vs. 251 days) (NS)
MDFT vs. ACRA:
Mean total number of days abstinent from cannabis use over 12-mo follow-up slightly lower for MDFT
MDFT vs. IP:
Prevalence of dependence on cannabis at 12-mo follow-up (38% vs. 52%) (SNR)
Prevalence of abuse of cannabis at 12-mo follow-up (33% vs. 22%) (SNR)
Prevalence of no longer experiencing cannabis use disorder at 12-mo follow-up (18% vs. 15%) (SNR)
Reduction in mean number of cannabis consumption days 43% (35 days) vs. 31% (SNR)
MDFT achieved better results for reduction in number of dependence symptoms
Reduction in frequency of cannabis consumption for HS group only (SNR)
Baldwin et al. (2012)
Dennis et al. (2004), Liddle et al. (2001), Liddle et al. (2004), Liddle et al. (2008a)
Objective: to evaluate the post-treatment effects of different types of family therapies on adolescent substance abuse and delinquency as compared to TAU, alternative therapies and controls
Design: Systematic review and meta-analysis of RCTs published up to February 2009.
N= 4 of 24 RCTs retrieved relevant to MDFT
Setting: US
Study duration: not reported
Youth aged 11-19 years
Participant population from relevant RCTs: total n=441; no characteristics reported.
MDFT
&
Group therapy
PGT
MET/CBT5
ACRA
Aggregate measure of all study outcomes on substance abuse and delinquency
MDFT vs. aggregate of all alternative treatments: SMD, 0.22; 95% CI, -0.16 to 0.60; p=0.21
Effectiveness of Multidimensional Family Therapy for Reducing Substance Use among Youth
Canadian Centre on Substance Abuse • Centre canadien de lutte contre les toxicomanies Page 14 Page 14
ACRA: adolescent community reinforcement approach; AGT: adolescent group treatment; CBT: cognitive-behavioural therapy; CI: 95% confidence interval; DOC: drug of choice; hrs: hours; EMCDDA: European Monitoring Centre for Drugs and Drug Addiction; HS: higher severity; IP: individual psychotherapy; LS: lower severity; MDFT: multidimensional family therapy; MEI: multifamily educational therapy; MI: motivational interviewing; mo: month; NS: non-significant; PGT: peer group treatment; RCT: randomized controlled trial; SMD: standardized mean difference; SNR: significance not reported; SS: statistically significant; TAU: treatment as usual; vs.: versus; wk: week
Bender et al. (2011)
Liddle et al. (2001), Liddle et al. (2004), Liddle et al. (2008a)
Objectives: to investigate the effects of interventions to reduce adolescent cannabis use and to conduct a comparison of the effects of individual vs. family-based treatments.
Design: Systematic review and meta-analysis of experimental or quasi-experimental studies published 1960-2008.
N=3 of 17 studies retrieved relevant to MDFT
Setting: all single site, United States
Study duration: up to 12-mo follow-up
Youth aged 12-19 years
Participant population: number and characteristics not reported overall or for relevant studies.
MDFT: n=36-47
&
Group therapy: n=28
Peer group treatment: n=40
CBT: n=35-53
Aggregate measure of all study outcomes quantifying cannabis use frequency at 3-mo follow-up:
MDFT vs. CBT: SMD, -0.25, 95% CI, -0.64 to 0.14; p=0.20
MDFT vs. PGT: SMD, -0.61; 95% CI, -1.06 to -0.15; p=0.009
Aggregate measure of all study outcomes quantifying cannabis use frequency at 6-mo follow-up:
MDFT vs. CBT: SMD,-0.09; 95% CI, -0.47 to 0.30; p=0.65
MDFT vs. group therapy: SMD, -0.59; 95% CI, -1.09 to -0.10; p=0.02;
MDFT vs. PGT: SMD, -0.61; 95% CI, -1.06 to -0.15; p=0.009
Aggregate measure of all study outcomes quantifying cannabis use frequency at 12-mo follow-up:
MDFT vs. CBT: SMD, -0.06; 95% CI, -0.48 to 0.36; p=0.79
MDFT vs. group therapy: SMD, -0.57; 95% CI, -1.06 to -0.07; p=0.02
Tripodi et al. (2010)
Liddle et al.
(2001), Liddle
et al. (2008)
Objectives: to assess the effectiveness of substance use interventions for their ability to reduce adolescent alcohol use and to compare the effects of individual treatments with family-based approaches.
Design: Systematic review and meta-analysis of experimental or quasi-experimental studies published studies 1960-2008.
N=2 of 16 studied retrieved were relevant to MDFT
Setting: Outpatient clinics; US
Study duration: up to 12-mo follow-up
Youth aged 12-19 years
Participant population: number and characteristics not reported overall or for relevant studies.
MDFT: 1 session/wk for 16 wks; n=14-39
&
Group therapy: n=28
CBT: n=49-59
Aggregate measure of all study outcomes quantifying alcohol use (abstinence, frequency and quantity of drinking at 3-mo follow-up:
MDFT vs. CBT: SMD, -0.40, 95% CI, -0.79 to -0.01; p=0.04
Aggregate measure of all study outcomes quantifying alcohol use (abstinence, frequency and quantity of drinking at 6-mo follow-up:
MDFT vs. CBT: SMD, -0.19, 95% CI, -0.58 to 0.20; p=0.33
MDFT vs. group therapy: SMD, -0.59; 95% CI, -1.09 to -0.10; p=0.02
Aggregate measure of all study outcomes quantifying alcohol use (abstinence, frequency and quantity of drinking at 12-mo follow-up:
MDFT vs. CBT: SMD, -0.17; 95% CI, -0.58 to 0.25; p=0.44
MDFT vs. group therapy: SMD, -0.57; 95% CI, -1.06 to -0.07; p=0.02
Effectiveness of Multidimensional Family Therapy for Reducing Substance Use among Youth
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Disclaimer: Rapid reviews are produced using accelerated and streamlined systematic review methods, usually in response to a
question or topic identified by the field. The information in this rapid review is a summary of available evidence based on a limited
literature search. CCSA does not warrant the currency, accuracy or completeness of this rapid review and denies any representation,
implied or expressed, concerning the efficacy, appropriateness or suitability of any intervention or treatment discussed in it.